By Stephanie Prendergast, MPT, Cofounder, PHRC Los Angeles
Connective tissue (CT) restrictions are defined as a dense thickening of subcutaneous tissue that’s painful upon pinch-rolling examination. Connective tissue restrictions can contribute to urinary and bowel symptoms and pelvic pain. As this post will explain, CT restrictions can be a cause and consequence of multiple pelvic floor symptoms and syndromes. During a PFPT evaluation for someone with pelvic pain, we examine the CT in the abdomen, the CT attached to the bony pelvis (front & back!), low back, gluteal region & the legs. When CT is restricted there’s less blood flow to the area, which makes tissues more sensitive than they should be when touched.
They’re also more sensitive to other things such as underwear & clothing, or sitting surfaces, which is why they can contribute to pain with sitting. Pelvic pain symptoms are often caused by multiple impairments, CTs should always be evaluated to determine if they are restricted or impaired. When people come to us that have not improved with PFPT previously, this is often a missing piece.
The techniques to examine and treat CT are very specific and must be done properly and consistently to help effectively identify and then treat the issues. In this blog we are going to discuss: the symptoms that CT restrictions cause, why they develop, how we treat them and what you can do at home to help restore normal and healthy tissue mobility! Want to read more about Connective Tissue Manipulation? Check out our blog that talks about ‘skin rolling’.
Research shows that connective tissue restrictions (CTRs) develop because of several reasons. Here are just a few of the main culprits.
Visecro-somatic reflexes: The term ‘Viscero’ means ‘organ’, ‘somatic’ refers to ‘muscle, nerves, and fascia.’ When visceral structures, such as a bladder, uterus, prostate, or part of the GI Tract get irritated they can have consequences in the muscles and tissues and as a result, CTRs can form.
Studies show that fascia above myofascial trigger points can develop CTRs in response to the inflammatory mediators that exist with myofascial trigger points.
When peripheral nerves become irritated there are consequences in the muscles and skin that those nerves innervate. For example, people with sciatic may develop CTRs in their legs in the sensory distribution of the sciatic nerve.
Similar to muscular dysfunction, joint dysfunction can release inflammatory mediators that result in the formation of CTRs superficial to the involved joint.
As we mentioned earlier in this post, connective tissue restrictions (CTRs) are dense thickening of fascia that is painful upon examination. CTRs can cause local tissue sensitivity & pain, for example, when they occur near the sit bones people may feel pain when they sit because sensitive, dense tissues are being further compressed and blood flow decreases even further.
CTRs can be caused by noxious input from visceral structures. For example, UTI ‘s and diseases such as Endometriosis can cause connective tissue to become impaired via the viscero-somatic reflex. The reverse also occurs: CTRs can cause irritative bladder symptoms, vulvar pain, and GI distress via the somatic-visceral reflex.
People with pelvic pain commonly develop CTRs in the dermatomes of peripheral nerves, such as the pudendal nerve, posterior femoral cutaneous nerve, or others. The density of the CTRs can cause mobility issues along the nerve & prevents the nerve from gliding, sliding, and moving normally. The CTRs can also compress peripheral nerves. Both scenarios can result in symptoms of peripheral neuralgia anywhere in the territory of the compromised nerve.
CTRs reduce blood flow to underlying muscles and also impair the ability of the underlying muscle to move normally. This increases the likelihood of the underlying muscles to be injured. In addition, CTRs may impair underlying tight muscles or trigger points to respond to therapies.
Connective tissue restrictions (CTRs) are associated with pelvic pain syndromes. They can be a cause or an effect of multiple inputs, and they themselves are a source of pain and dysfunction. While CTRs are problematic, if they are present they can be treated several ways.
PFPTs utilize a manual therapy technique called connective tissue manipulation which involves a ‘skin rolling’ technique to reduce dense tissues, improve blood flow, and help restore normal mobility and sensation to the impaired tissues. When done properly this technique is well tolerated & patients usually feel relief of bothersome symptoms immediately after treatment and over time.
Cupping is a technique that involves using suction to lift fascia. Cupping can be static or the therapist may use dynamic techniques that involve moving the cups or the body to help tissues slide, glide and move more normally.
Foam rolling helps mobilize the fascia as well as reduce myalgia and muscle tension in the underlying muscle group. This is great for the legs and trunk but the areas of the bony pelvis, pudendal nerve, and tissues closest to the vagina & anus are better treated with cupping plus manual therapy.
Finally, CTRs develop & persist because of visceral, joint, muscular, and neural dysfunction. Treating the underlying causes of the CTRs will allow for normalization of this problematic tissue. Examples of treating underlying causes include eliminating gut pathogens such as SIBO, eliminating UTIs and yeast infections, or treating underlying PFD or Endo.
Take home message: Connective Tissue Restrictions are associated with pelvic pain and should be evaluated to determine if they are playing a role in someone’s symptoms. If they are present, manual and home therapies can help restore normal mobility and reduce pain and dysfunction!
Read more:
Sitting on painful fascia: connective tissue and pelvic pain
Pelvic Pain: The Role of Scar Tissue
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Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.